Recommendations from a coroner's jury examining the death of a three-year-boy in foster care point to a glaring gap in Saskatchewan's foster-care system.
The child who died was placed in a foster home in Pense, Sask., in 2009 and cannot be identified because of a publication ban imposed by lawyer Alma Wiebe, the presiding coroner.
The child's foster parents, whose identities are also protected by a publication ban, testified the boy was ill and running a fever the week before he died. He was found dead in his crib Dec. 17, 2009. According to medical experts, he died of a chest infection.
The inquest learned that because of an underlying heart condition, the boy would have been at risk if he developed a fever — information that was not shared with the foster parents.
The jury's recommendations highlighted this failing, saying that in future foster-care placements a child's medical records should be available to parents.
Jurors also recommended that children with medical needs be placed in homes close to medical services. Pense is about 30 kilometres west of Regina.
Wiebe told CBC News the boy's death was "tragic." She added that the jury's recommendations might help prevent future deaths, although they are not binding on any agency.
The boy's grandmother told CBC News she hopes the Ministry of Social Services will follow the recommendations.
"This was a preventable death," the woman said. "We pray for all the children in care. This inquest took place to prevent this from happening to other children. One dies so many will live."
Bob Hughes, a community activist who was providing advice and support to the family of the dead boy, said he was concerned the recommendations would not be followed.
"We've seen lots of inquests," Hughes said. "We've seen lots of recommendations, and often times we haven't seen any action from those recommendations. So I think the value of this inquest is yet to be seen."
Andrea Brittin, an official from the Ministry of Social Services, told reporters the recommendations will be considered.